Provider Demographics
NPI:1366438939
Name:SOUTH JERSEY EYE ASSOCIATES PA
Entity type:Organization
Organization Name:SOUTH JERSEY EYE ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:COLE
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:856-455-5500
Mailing Address - Street 1:205 LAUREL HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-3635
Mailing Address - Country:US
Mailing Address - Phone:856-455-5500
Mailing Address - Fax:856-455-5480
Practice Address - Street 1:205 LAUREL HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-3635
Practice Address - Country:US
Practice Address - Phone:856-455-5500
Practice Address - Fax:856-455-5480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2799707Medicaid
NJ=========OtherTAX ID
NJ2799707Medicaid
NJ0213150001Medicare NSC